Home Dialysis Reimbursement & Financial Considerations Anthony Messana Nephrology Consulting & Management Services, LLC
Home Dialysis and MSP <ul><li>Medicare Secondary Payer Status –  Home Dialysis </li></ul><ul><ul><li>Initial 90 day period...
 
Initial Method Selection –  Beneficiary Selection Form CMS-382 <ul><li>Method I </li></ul><ul><li>Patient’s  Facility  pro...
Support Services – Method I <ul><li>Provide periodic monitoring of patient’s home adaptation </li></ul><ul><li>Emergency v...
Separately Billable Items <ul><li>Routine tests and medications are reimbursed the same as an incenter hemodialysis patien...
Home Peritoneal Dialysis Training
Home Hemodialysis <ul><li>Hemodialysis Machine </li></ul><ul><li>Water Treatment  </li></ul><ul><ul><li>Cultures & Water A...
CAPD Training <ul><li>Medicare allows 15 training treatments  per patient </li></ul><ul><ul><li>Additional training treatm...
CCPD Training Sessions <ul><li>Medicare allows 15 training sessions per patient </li></ul><ul><ul><li>Additional training ...
Home Hemodialysis  Training Rate <ul><li>Medicare allows 25 training treatments per patient </li></ul><ul><ul><li>Addition...
Training Reimbursement Example <ul><li>Patient A   Home Hemodialysis Candidate </li></ul><ul><li>Composite Rate:    $133.5...
Self Administration of EPOGEN  <ul><li>Congressionally legislated exception to Medicare Benefits </li></ul><ul><ul><li>All...
Medicare Payment Exception Requests <ul><li>Accelerated Home Training </li></ul><ul><ul><li>Average number of training ses...
Exception Requests <ul><li>Process for applying eliminated by CMS </li></ul><ul><li>Exceptions granted prior to July 2001 ...
Documentation – Key Factor in Successful Reimbursement <ul><li>For all services provided documentation should exist in the...
Home Dialysis Documentation <ul><li>Patient modality selection supported </li></ul><ul><ul><li>LTCP – patient input and si...
Medicare Payment Changes for 2005 <ul><li>Composite Rate will increase 1.6% </li></ul><ul><li>Medications will be reimburs...
Medicare Changes in Reimbursement starting in 2005 Support Home Dialysis Therapies <ul><li>Home dialysis patients – utiliz...
Social Security Disability Opportunities for Patients <ul><li>Trial Work Periods </li></ul><ul><ul><li>Disabled Beneficiar...
Medicaid Buy-In <ul><li>“ Ticket to Work” & “Work Incentives    Improvement Act”  </li></ul><ul><ul><li>Allows people with...
Aides with Commercial Insurance   <ul><li>During the coordination period some commercial insurance companies may pay  for ...
Questions
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  1. 1. Home Dialysis Reimbursement & Financial Considerations Anthony Messana Nephrology Consulting & Management Services, LLC
  2. 2. Home Dialysis and MSP <ul><li>Medicare Secondary Payer Status – Home Dialysis </li></ul><ul><ul><li>Initial 90 day period before qualifying for Medicare is waived </li></ul></ul><ul><ul><li>Medicare is secondary to commercial plans for the first 30 months of dialysis therapies </li></ul></ul><ul><ul><li>Medicare becomes primary on the 1 st day of the 31 st month after starting dialysis </li></ul></ul>
  3. 4. Initial Method Selection – Beneficiary Selection Form CMS-382 <ul><li>Method I </li></ul><ul><li>Patient’s Facility provides: </li></ul><ul><ul><li>All equipment, supplies </li></ul></ul><ul><ul><li>All support services </li></ul></ul><ul><li>Medicare pays the facility directly for all these supplies through an all inclusive daily rate </li></ul><ul><li>Method II </li></ul><ul><li>Patient’s Supplier provides: </li></ul><ul><ul><li>All equipment, supplies </li></ul></ul><ul><li>Medicare pays Supplier </li></ul><ul><ul><li>CCPD $1974.45 cap </li></ul></ul><ul><ul><li>CAPD $1490.85 cap </li></ul></ul><ul><li>Patient’s Facility provides </li></ul><ul><ul><li>All support services </li></ul></ul><ul><li>Medicare pays Facility </li></ul><ul><ul><li>$121.15 for support services </li></ul></ul>Beneficiary selection forms can be changed annually but must be submitted prior to January 1 to take effect. Send them certified to the FI 2~4 weeks before January 1.
  4. 5. Support Services – Method I <ul><li>Provide periodic monitoring of patient’s home adaptation </li></ul><ul><li>Emergency visits by facility personnel </li></ul><ul><li>Providing for and arranging supplies </li></ul><ul><li>Installation and maintenance of the dialysis equipment </li></ul><ul><li>ESRD related routine lab tests </li></ul><ul><li>Testing and appropriate water treatment </li></ul><ul><li>Monitoring of the functionality of the dialysis equipment </li></ul><ul><li>For CAPD & CCPD the following is added: </li></ul><ul><li>Changing the tubing </li></ul><ul><li>Watching the patient perform PD and assuring that it is done correctly </li></ul><ul><li>Documentation of peritonitis </li></ul><ul><li>Inspection and monitoring of patient’s catheter site </li></ul>
  5. 6. Separately Billable Items <ul><li>Routine tests and medications are reimbursed the same as an incenter hemodialysis patient </li></ul><ul><ul><li>Antibiotics for treating peritonitis are only reimbursed when they are administered in the unit. </li></ul></ul><ul><ul><ul><li>Facilities must provide injectable antibiotics for treating peritonitis and exit site infections for patients to self administer at home </li></ul></ul></ul>
  6. 7. Home Peritoneal Dialysis Training
  7. 8. Home Hemodialysis <ul><li>Hemodialysis Machine </li></ul><ul><li>Water Treatment </li></ul><ul><ul><li>Cultures & Water Analysis </li></ul></ul><ul><li>Supplies </li></ul><ul><li>Initiation & Termination of Treatment </li></ul><ul><li>Preparation for Emergencies </li></ul><ul><li>Self Administration of EPOGEN </li></ul>
  8. 9. CAPD Training <ul><li>Medicare allows 15 training treatments per patient </li></ul><ul><ul><li>Additional training treatments are allowed if documentation exists for the need for more treatments to achieve a successful training session </li></ul></ul><ul><li>Medicare reimbursement rate </li></ul><ul><ul><li>Local Composite Rate plus $15.00 per session </li></ul></ul>
  9. 10. CCPD Training Sessions <ul><li>Medicare allows 15 training sessions per patient </li></ul><ul><ul><li>Additional training sessions are allowed if documentation exists for the need for more sessions to achieve a successful training session </li></ul></ul><ul><li>Medicare reimbursement rate </li></ul><ul><ul><li>Local Composite Rate plus $20.00 per session </li></ul></ul>
  10. 11. Home Hemodialysis Training Rate <ul><li>Medicare allows 25 training treatments per patient </li></ul><ul><ul><li>Additional training treatments are allowed if documentation exists for the need for more treatments to achieve a successful training session </li></ul></ul><ul><li>Medicare reimbursement rate </li></ul><ul><ul><li>Local Composite Rate plus $20.00 per session </li></ul></ul>
  11. 12. Training Reimbursement Example <ul><li>Patient A Home Hemodialysis Candidate </li></ul><ul><li>Composite Rate: $133.57 per treatment </li></ul><ul><li>Training Rate: $153.57 per training session ($133.57 + $20.00 training add on) </li></ul><ul><li>Patient A required 21 sessions to complete training </li></ul><ul><li>Each Session would be billed at $153.57 </li></ul><ul><li>Total Reimbursement 21 x $153.57 = $3224.97 </li></ul><ul><li>Patient B CAPD Candidate </li></ul><ul><li>Composite Rate: $133.57 per treatment </li></ul><ul><li>Training Rate: $148.57 per training session ($133.57 + $15.00 training add on) </li></ul><ul><li>Patient B required 7 sessions to complete training </li></ul><ul><li>Each Session would be billed at $148.57 </li></ul><ul><li>Total Reimbursement 7 x $148.57 = $1039.99 </li></ul>
  12. 13. Self Administration of EPOGEN <ul><li>Congressionally legislated exception to Medicare Benefits </li></ul><ul><ul><li>Allows units to train patients to self administer EPOGEN </li></ul></ul><ul><ul><li>Allows units to bill for EPOGEN sent home to patients </li></ul></ul><ul><ul><ul><li>Bill the amount given to the patient not the based on specific dose amount – patient can maintain up to a 2 month supply of EPOGEN for self administration </li></ul></ul></ul>
  13. 14. Medicare Payment Exception Requests <ul><li>Accelerated Home Training </li></ul><ul><ul><li>Average number of training sessions is less than Medicare allows </li></ul></ul><ul><ul><li>Cost of training exceeds Medicare payment </li></ul></ul><ul><ul><li>Documentation supports the exception request </li></ul></ul><ul><li>Isolated Essential Facility </li></ul><ul><li>Atypical Patient Mix </li></ul><ul><li>It is too bad the Medicare and Congress closed this opportunity except for pediatric programs who did not have an exception as of October 2002 </li></ul>
  14. 15. Exception Requests <ul><li>Process for applying eliminated by CMS </li></ul><ul><li>Exceptions granted prior to July 2001 are grandfathered in and will remain in effect until the exception rate is below the Medicare composite rate, at which time the payment will revert to the higher of the two </li></ul><ul><li>Cost reports and record keeping are important should the exception window open at some future date </li></ul>
  15. 16. Documentation – Key Factor in Successful Reimbursement <ul><li>For all services provided documentation should exist in the patients chart that: </li></ul><ul><ul><li>Provides clinical tracking of a patients progress </li></ul></ul><ul><ul><li>Provides clinical rationale for the selected modality </li></ul></ul><ul><ul><li>Justifies the therapies provided – </li></ul></ul><ul><ul><ul><li>a. Dialysis treatment – why was this modality chosen, how does it benefit the patient’s clinical outcome, how is it monitored </li></ul></ul></ul><ul><ul><ul><li>b. Medications – supported and monitored, protocols </li></ul></ul></ul><ul><ul><ul><li>c. Laboratory services – reviewed and supports therapies </li></ul></ul></ul>
  16. 17. Home Dialysis Documentation <ul><li>Patient modality selection supported </li></ul><ul><ul><li>LTCP – patient input and signature </li></ul></ul><ul><li>If more frequent care is required then this is supported by medical conditions which may include: </li></ul><ul><ul><li>Cardiac conditions </li></ul></ul><ul><ul><li>Rehabilitation – return or maintenance of work </li></ul></ul><ul><ul><li>Improved clinical outcomes – including but not limited to adequacy of dialysis, improved blood pressure control, better anemia management </li></ul></ul><ul><ul><li>It is up to the physician to medically justify the course of care for the patient </li></ul></ul>
  17. 18. Medicare Payment Changes for 2005 <ul><li>Composite Rate will increase 1.6% </li></ul><ul><li>Medications will be reimbursed at cost – possibly 85% of AWP or some other determined costs </li></ul><ul><li>OIG & Medicare will determine an add-on amount to the composite rate for the average margin from medications based on the following: </li></ul><ul><ul><li>2004 utilization of medications per treatment </li></ul></ul><ul><ul><li>Cost of Medications – sources pharmaceutical companies and audit submission by providers </li></ul></ul><ul><ul><li>Amount of margin for these medications based on average utilization </li></ul></ul>
  18. 19. Medicare Changes in Reimbursement starting in 2005 Support Home Dialysis Therapies <ul><li>Home dialysis patients – utilize fewer medications and under the current reimbursement scheme receive less margin from the medications </li></ul><ul><ul><li>MedPAC reports show that the composite rate without the average amount of medications administered looses money </li></ul></ul><ul><li>Under the new reimbursement rate the home patient will receive the add on to the composite rate for the average margin per treatment based on the average amount of drug administered </li></ul>
  19. 20. Social Security Disability Opportunities for Patients <ul><li>Trial Work Periods </li></ul><ul><ul><li>Disabled Beneficiaries are able to work 9 “trial” months every 5 years – these months are only used when the income exceeds $580 </li></ul></ul><ul><li>Impairment related work expenses (IRWE), include the costs to have aides for home dialysis, will be deducted from the patient’s income when calculating income </li></ul><ul><ul><li>After IRWE deductions patients can earn up to $810 per month in 2004 ($1350 if legally blind) before disability payments will cease </li></ul></ul>
  20. 21. Medicaid Buy-In <ul><li>“ Ticket to Work” & “Work Incentives Improvement Act” </li></ul><ul><ul><li>Allows people with disabilities to have more income than non-working disabled individuals and still qualify for Medicaid benefits. </li></ul></ul>
  21. 22. Aides with Commercial Insurance <ul><li>During the coordination period some commercial insurance companies may pay for an aide to assist the patient. </li></ul><ul><li>Have the patient check with their insurance provider </li></ul>
  22. 23. Questions
  23. 24. The End

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